Provider Demographics
NPI:1194815886
Name:BLAIR, ROBERT VAN (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:VAN
Last Name:BLAIR
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 69
Mailing Address - Street 2:
Mailing Address - City:WINNSBORO
Mailing Address - State:TX
Mailing Address - Zip Code:75494-0069
Mailing Address - Country:US
Mailing Address - Phone:903-342-3710
Mailing Address - Fax:903-342-3709
Practice Address - Street 1:719 W COKE RD
Practice Address - Street 2:SUITE 1, BLDG 1
Practice Address - City:WINNSBORO
Practice Address - State:TX
Practice Address - Zip Code:75494-3011
Practice Address - Country:US
Practice Address - Phone:903-342-3710
Practice Address - Fax:903-342-3709
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-13
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH5842208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX10724731OtherCAQH ID
TX117273Medicaid
020011155Medicare ID - Type UnspecifiedRAILROAD MEDICARE
E77084Medicare UPIN
D16DMedicare ID - Type Unspecified